Author: David Gratzer

Reading of the Week: School-based CBT for Teens – the New Lancet Psych Study; Also, Rural vs Urban Readmissions, and Dr. Horton on Fighters (and Biden)

From the Editor

Though many years have passed, he clearly remembers his first depressive episode, which occurred before his 18th birthday. My patient often wonders how things could have been different had he been offered care earlier. School-based initiatives are much discussed – indeed, they are having a moment. Public schools, for example, in New York City, offer students a few minutes daily of teacher-led mindful breathing. Such efforts are unlikely to yield significant results, in part because they lack focus.

What if we offered psychotherapy skills to interested high school students? Could it help alleviate symptoms of mood and anxiety? Would it be cost effective? June Brown (of King’s College London) and her co-authors address these questions in a new study just published in The Lancet Psychiatry. They report on a randomized controlled trial involving 900 UK adolescents who self-referred and received CBT or treatment-as-usual. “[T]he DISCOVER intervention is modestly clinically effective and economically viable and could be a promising early intervention in schools.” We consider the paper and its implications.

In the second selection, drawing on US data, Hefei Wen (of Harvard University) and co-authors examine hospital readmissions in the United States for mental health. In this new research letter published in JAMA Psychiatry, they find that rural readmissions – historically lower than urban ones – now exceed their urban counterparts. “This reversal and worsening of rural and urban gaps in mental health readmission was primarily concentrated in schizophrenia spectrum and other psychotic disorders, bipolar and related disorders, and depressive disorders.”

And in the third selection from the Los Angeles Times, Dr. Jillian Horton (of the University of Manitoba) discusses time, aging, and resilience in a personal essay. Our internist colleague touches on the debate over the US president and his health but focuses on the story of her sister, who faced major problems after neurosurgery. She notes that her sister was able to “beat the odds” many times, until she couldn’t. “[W]e can’t change the reality of what comes next.”

DG

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Reading of the Week: CBT vs Mindfulness for Prolonged Grief Disorder – the New JAMA Psych Study; Also, Wildman on Her Grief, and Clozapine & MedEd

From the Editor

She still wears black. She mourns her partner’s death every day. Despite the passing years, she can’t seem to move forward. DSM-5-TR includes prolonged grief disorder, which has sparked controversy, but it explains well my patient’s complicated bereavement.

What’s evidenced for treatment? Is CBT superior to mindfulness? Richard A. Bryant (of the University of New South Wales) and his co-authors try to address these questions in a new JAMA Psychiatry paper. They describe a randomized clinical trial involving 100 adults offered CBT or mindfulness-based cognitive therapy. “In this study, grief-focused cognitive behavior therapy conferred more benefit for core prolonged grief disorder symptoms and associated problems 6 months after treatment than mindfulness-based cognitive therapy.” We consider the paper and its implications.

In the second selection, Sarah Wildman, a writer and editor, discusses her daughter’s death in an essay for The New York Times. She is candid about her grief. She talks about the passage of time, small things like calendars, and, yes, signs – her daughter promised that if she sees a red fox, it will be her. “I wonder if I should keep every item of clothing I can picture Orli in, I wonder what she would say about each movie I see, each book I read.”

In the third selection, Dr. Theodore R. Zarzar (of the University of North Carolina) emphasizes the importance of clozapine in the treatment of patients with schizophrenia. In his JAMA Psychiatry Viewpoint, he argues for incorporating clozapine proficiency into medical education. “Clozapine initiation can be conceptualized as the community psychiatric equivalent of a procedural skill and deserves the mentorship, knowledge acquisition, and practice that learning a procedure entails.”

DG

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Reading of the Week: Psychological Interventions for Schizophrenia – the New Lancet Psych Study; Also, Service Dogs for PTSD, and the Latest in the News

From the Editor

She was distressed by the voices and the paranoid thoughts. Many nights, my patient could barely sleep. She had tried several medications without much improvement. Is there a role for psychological interventions? Would CBT help? What is the evidence for this population?

In the first selection, Nurul Husna Salahuddin (of the Technical University of Munich) and co-authors attempt to answer these questions in a new systematic review and network meta-analysis, just published in Lancet Psychiatry. The analyzed 52 RCTs with 5 034 participants. “We provide robust findings that CBTp can reduce the overall symptoms of patients with treatment-resistant schizophrenia, and therefore clinicians can prioritise this intervention in their clinical practice.” We consider the paper and its clinical implications.

In the second selection from JAMA Network Open, Sarah C. Leighton (of the University of Arizona) and her co-authors describe a study involving service dogs for those with PTSD. In a nonrandomized controlled trial involving 156 military members and veterans, they examined outcomes after three months. “[C]ompared with usual care alone, partnership with a trained psychiatric service dog was associated with lower PTSD symptom severity and higher psychosocial functioning in veterans.”

Finally, we explore the latest news with recent articles from The Guardian, the Ottawa Citizen, and The New York Times. Among the topics: “honest” obituaries and the opioid crisis, antidepressants and withdrawal, and care for pregnant women with substance problems.

DG

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Reading of the Week: Antidepressants & Discontinuation Symptoms – the New Lancet Psych Study; Also, Neuromodulation and Digital Health Technology

From the Editor

“Once I start taking them, I’m stuck.” When discussing the possible initiation of an antidepressant trial, a patient recently expressed his fear: that he wouldn’t be able to stop the medication because of discontinuation symptoms. These symptoms are debated. Some claim they are very common – though that’s not widely reported in the literature. 

How frequently do these symptoms occur? What percentage of patients experience severe symptoms? Are some antidepressants more associated with this problem than others? Dr. Jonathan Henssler (of the University of Cologne) and his co-authors attempt to answer these questions with an impressive, new systematic review and meta-analysis, published in Lancet Psychiatry. They drew on 79 studies involving more than 21 000 people. “The incidence of antidepressant discontinuation symptoms is approximately 15%, affecting one in six to seven patients who discontinue their medication.” We consider the paper and its clinical implications.

Will the stigma around ECT fade? Will ECT eventually be replaced by ketamine and MST? What’s the future of neuromodulation? We answer these questions and more in the second selection, the latest Quick Takes podcast interview. Dr. Daniel Blumberger, scientific director of CAMH’s Temerty Centre for Therapeutic Brain Intervention and professor at the University of Toronto, notes that ECT still has a unique place. “As far as medical treatments go, ECT is the safest medical procedure in all of medicine.”

And in the third selection, Dr. John Torous (of the Harvard University) and his co-authors focus on digital mental health in a new Viewpoint published in JAMA Psychiatry. They argue that we tend to both overstate and underappreciate the risks and benefits of digital mental health interventions. “Patients and clinicians should not assume wellness digital health technologies are always dangerous, nor should they assume health technologies are always safe.”

DG

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Reading of the Week: Cancer & Suicide & Good News – the New Transl Psychiatry Study; Also, AI & Therapy Dropouts, and Bland on Her Father & His D-Day

From the Editor

He was so overwhelmed by the cancer diagnosis that he didn’t eat or sleep for days. “It was my worst nightmare.” My patient isn’t alone in that devastating experience, of course – the diagnosis and treatment of cancer is a major life event. Not surprisingly, the suicide rate is roughly double that of the general population in the United States. But with increasing psychosocial interventions, how has this changed over time?

In the first selection, Qiang Liu (of the Chinese Academy of Medical Sciences) and his co-authors attempt to answer that question in a new paper for Translational Psychiatry. Drawing on 40 years of data and a major US database, they analyzed the journeys of five million cancer patients, discovering good news. “We revealed a gradual increase in cancer-related suicide rates from 1975 to 1989, followed by a gradual decrease from 1989 to 2013, and a marked decrease from 2013 to 2017.” Indeed, between 2013 and 2017, the rate dropped by 27%. We consider the paper and its implications.

In the second selection, Sakiko Yasukawa (of the Sony Corporation) and her co-authors aimed to reduce dropouts from psychotherapy using AI. In a new paper for BMJ Mental Health, they describe an RCT involving 149 people. “The results suggest that the personalised messages sent by the chatbot helped participants control their pace in attending lessons and improve programme adherence without human guidance.”

Last week marked the anniversary of D-Day with ceremonies, including in Normandy. What was the toll on those who returned home? In the third selection, an essay published in The Globe and Mail, Normanne Bland describes her father and his time in Europe. She writes about him with mixed feelings, coloured by his mental health problems, including PTSD. “I had a complicated relationship with my father. I was proud of his service but I loathed his drinking.”

There will be no Reading next week.

DG

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Reading of the Week: Placebo & Mental Disorders – the New JAMA Psych Study; Also, Children Who Lost a Parent to Overdose, and the Latest in the News

From the Editor 

It’s day three of his hospitalization, and he insists that the medication trial (a low dose of an SSRI) has been transformative. It’s difficult to explain his experience pharmacologically. 

How significant is the placebo response? How much does it vary among mental disorders? These questions aren’t new. In the first selection, Dr. Tom Bschor (of the Technical University of Dresden) and his co-authors tread on a familiar path with a study just published in JAMA Psychiatry. Focusing on nine psychiatric disorders, they examined high-quality RCTs for a systematic review and meta-analysis, finding “significant improvement under placebo treatment for all 9 disorders, but the degree of improvement varied significantly among diagnoses.” We consider the study and its implications.

In the second selection, Christopher M. Jones (of the Substance Abuse and Mental Health Services Administration) and his co-authors used US databases to calculate how many children have lost a parent to drug overdoses. The resulting JAMA Psychiatry study is haunting. “We estimated that more than 320 000 US children lost a parent to drug overdose between 2011 and 2021, providing new insight into the multigenerational impacts of the ongoing overdose crisis in the US.”

Finally, we explore the latest news with recent articles from The GuardianThe Globe and Mail, and The New York Times. Among the topics: the mental health struggles of a cancer patient, the beliefs of Marshall Smith, and whether we are talking too much about mental health.

DG

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Reading of the Week: Are Mental Disorders Contagious in Teens? The New JAMA Psych Study; Also, Edibles & Older Adults, and Harmon on Discrimination

From the Editor

People with mental disorders often have family members who have been touched by illness – a genetic tie, well established in the literature. But what about the influence of peer groups? A small body of literature suggests a connection between social circles and diagnosis. How can we understand this? Are mental disorders contagious?

In the first selection, Jussi Alho (of the University of Helsinki) and her co-authors attempt to answer those questions in a new study for JAMA Psychiatry. They did a cohort study, drawing on Finnish databases, and involving more than 700 000 people. They considered individuals who had a classmate diagnosed with a mental disorder in grade 9. “We found an association between having peers diagnosed with a mental disorder during adolescence and an increased risk of receiving a mental disorder diagnosis later in life.” We analyze the study and its implications.

How have cannabis poisonings increased with the legalization of edibles in Canada? In the second selection, a research letter for JAMA Internal Medicine, Dr. Nathan M. Stall (of the University of Toronto) and his co-authors looked at an 8-year period and focused on older adults, finding 2 322 ED visits in Ontario. “The largest increases occurred after edible cannabis became legally available for retail sale, a phenomenon similarly observed in Canadian children.”

And in the third selection, Caroline Payton Harmon, who is a PhD candidate at Rutgers University, describes the people she met in substance use treatment. The essay, published in The Lancet Psychiatry, is personal and notes the contrasts between those of different socioeconomic backgrounds. “The health-care system sees money and sees patients who are not worth the cost of treatment.”

DG

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Reading of the Week: the CANMAT Depression Update – Seven Takeaways & Commentary; Also, Patient Preferences for Televideo Backgrounds

From the Editor

Much has changed in the past eight years. In 2016, singer Olivia Rodrigo was starting high school. Quarterback Tom Brady seemed ageless. And none of us were talking about pandemics. 2016 was also the year when the last Canadian Network for Mood and Anxiety Treatments (CANMAT) depression guidelines were released. Well, it’s 2024 and the update has just been published in The Canadian Journal of Psychiatry

How has depression management changed over these past eight years, and how should you adjust your clinical practice? In the first selection, we look at seven takeaways and a commentary.

Melancholia (from the Wellcome Library)

In this week’s other selection, Dr. Nathan Houchens (of the University of Michigan) and his co-authors consider telemedicine video backgrounds in a new research letter from JAMA Network Open. They asked patients to rate different backgrounds and in various medical circumstances; they report on survey results of more than 1 200 patients. “In this study, two-thirds of participants preferred a traditional health care setting background for video visits with any physician type, with physician office displaying diplomas rated highest.”

DG

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Reading of the Week: Adolescent Experience with Illness – the World Psych Paper; Also, the CANMAT Depression Update and a Letter to the Editor

From the Editor

I’m separated from everyone else.

These are the words of a young patient with depression. We often use diagnoses and lists of symptoms to understand patients. But how do patients themselves understand their illness? In the first selection, Dr. Paolo Fusar-Poli (of King’s College London) and his co-authors attempt to answer that question with a “bottom-up” approach. In a new World Psychiatry paper, they describe the experiences of adolescents with mental disorders. “The study was co-designed, co-conducted and co-written by junior experts by experience – representing different genders, ethnic and cultural backgrounds, and continents – and academics, refining an earlier method developed by our group to investigate the lived experience of psychosis and depression.” We examine the paper and its implications.

Childhood depression by Marc-Anthony Macon

Much has changed over the past eight years – who was talking about pandemics in 2016? Last week, the Canadian Network for Mood and Anxiety Treatments (CANMAT) released its first major depression update in eight years. So how has depression management changed? In the second selection, Dr. Raymond Lam (of the University of British Columbia), the co-first author, discusses the update in a Quick Takes podcast interview. “They really are the most widely used guidelines in the world.” 

And in the third selection, in a letter to the editor, Nick Kerman (of the University of Toronto) writes about the recent homelessness paper from JAMA Psychiatry, summarized in a Reading earlier this month. He notes the striking finding: 26% meet the criteria for antisocial personality disorder. “Could it really be 1 in 4 or is there something else that could explain the finding?”

DG

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Reading of the Week: Cannabis & Cardiac Health – the New JAHA Study; Also, Burnout & Outcomes, and Dr. Mary Seeman on Scaling Down

From the Editor

Our patients increasingly use cannabis, and we worry about the impact on their mental health. But what about the impact on their physical health?

In the first selection, Abra M. Jeffers (of Harvard University) and her co-authors consider cannabis and cardiac health. In a new paper for the Journal of the American Heart Association, they analyzed cardiac outcomes, drawing on survey data and involving more than 400 000 participants, some of whom used cannabis. “Cannabis use is associated with adverse cardiovascular outcomes, with heavier use (more days per month) associated with higher odds of adverse outcomes.” We review the paper and its implications.

In the second selection, Nina A. Sayer (of the University of Minneapolis) and her co-authors look at burnout in a new paper for JAMA Network Open. In a cohort study involving 165 therapists and almost 1 300 patients, they note a connection between provider burnout and PTSD outcomes. “These findings suggest that interventions to reduce therapist burnout might also result in more patients experiencing clinically meaningful improvement…”

Dr. Mary Seeman (of the University of Toronto), who died in late April, had a storied career as a psychiatrist. She had major roles, including the Tapscott Chair in Schizophrenia at the University of Toronto. In a 2003 paper for The American Journal of Psychiatry, she reflects on her work with a patient. This essay – the third selection this week – notes the decades-long connection between doctor and patient. “Her faith in me keeps me coming into work each morning, often tired and achy, sometimes trying unsuccessfully to remember the comforting word I want to be able to say.”

DG

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